THRIVE WITH ME THERAPY OT/PT Application
Independent Contractor (PRN)
Name
First Name
Middle Name
Last Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Select position applying for::
Please Select
Occupational Therapist (0T)
Physical Therapist (PT)
Occupational Therapy Assistant (OTA)
Physical Therapy Assistant(PTA)
Total number of years experience::
SOCIAL SECURITY NUMBER OR ITIN
Date of Birth
-
Month
-
Day
Year
Date
I meet the following requirements (check all that apply):
Passion for people and/or disabled persons
Knowledgeable about ages & stages
2 Job or Personal References
Clean Background Check
Reliable & prompt
Able to commit to job timeline
18+ years old
Clear driving record
Safe & ensured vehicle
Current CPR/FA certification or willingness to renew
Willing to take drug test
Are you authorized to work In The United States?
*
Yes
No
Are you willing to get South Carolina Sled background completed at your own cost? https://catch.sled.sc.gov/
*
Yes
No
Do you own your own vehicle or Have reliable transportation?
Yes
No
Do You Have A Drivers License? If so, submit 3 year driving record at your cost https://www.scdmvonline.com/
*
Yes
No
Areas you are comfortable commuting to: (within South Carolina limits)
Distance Willing To Travel?
Please Select
Over 30 Mile Radius
Below 30 Mile Radius
Public Transit Only
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date You Can Start
-
Month
-
Day
Year
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Position Interested In (check all that apply):
Part Time
On Call
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Skills/Qualifications:
Introduce yourself to a prospective employer by sharing a personal letter about your experience.
Important Note: This is much more than a job to us. We are looking for caregivers that understand the significance of being welcomed into a family. Additionally, we highly value professional letters written with attention to detail (grammar, punctuation, etc.).
List three words that describe your personality:
What skills and experience do you have that are useful for OT/PT? Feel free to be as in depth as possible.
CPR/First Aid Certified?
Please Select
Yes
No
Willing to Get Certified
CPR/First Aid Expiration Date
-
Month
-
Day
Year
List any additional health & safety trainings:
Shift Availability
*
Upload current Indentification (ID) or Drivers License (DL) (5MB or smaller gif, png, jpg, or jpeg file)
*
Browse Files
Drag and drop files here
Choose a file
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of
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Education:
Highest Level of Education:
Please Select
High School
College
Graduate School
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
College
Name of College/University Attended
Graduated College?
Please Select
Yes
No
Number of Years Attended College
College Area of Study/Degree
Graduate School
Name of Graduate School Attended
Graduated Grad School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Graduated From Trade School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
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Upload current professional licenses, certificates, and/or diplomas(5MB or png smaller,gif,jpg, or jpeg file)
*
Browse Files
Drag and drop files here
Choose a file
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Previous Employment or Contractor
Previous Employer or Contractor
i.e. Name of Family
Previous Employer or Contract Position
Your job title
Previous Employer or Contractor Start Date
-
Month
-
Day
Year
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Previous Employer or Contractor End Date
-
Month
-
Day
Year
Date Picker Icon
Previous Employer or Contractor Duties
Please include an in-depth job description
Previous Employer or Contractor Reason for Leaving
Previous Employer or Contractor May We Contact?
Yes
No
Other
Please explain why we may not contact your previous employer or contractor::
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References:
Please include at least three
May we contact your references?
Yes
No
Reference One
Name of Reference
Reference One Relationship
Reference One Years Acquainted
Reference One Phone
Reference One Email
example@example.com
Reference Two
Name of Reference
Reference Two Relationship
Reference Two Years Acquainted
Reference Two Phone
Reference Two Email
example@example.com
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Acknowledgement
*
AT-WILL EMPLOYMENTThe relationship between you and the Thrive With Me Therapy LLC is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Thrive With Me Therapy LLC. No representative of Thrive With Me Therapy LLC has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
Acknowledgement
*
Independent Contractor Agreement NoticeI understand that this application is for work as an independent contractor (PRN) and not as an employee. If accepted, I will be required to provide:Copy of state license and certificationsProof of liability insuranceW-9 Form for tax purposesBackground check authorization
Signature
*
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